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Wednesday, September 1, 2010

To all who have gone that way before

I am staring down the barrel of the residency match. Yes, I still have a year and a half until my match day, but there is a lot of planning that goes into the process ahead of time. I know it was a topic day here once. (Covered beautifully, I might add!) But, I have a specific concern, and a specific question.

The concern: I already have kids. I am a single mom.

The question: What is more important, what is inside the walls of the hospital, or outside?

Before I got separated, I was looking at programs based on certain factors: geographical location - was it a cool city where I've always wanted to live? (Like Portland, Oregon). Was the program a progressive program that seemed woman centered? (Like OHSU in Portland, Oregon.) Was it an academic program? (Like OHSU in Portland, Oregon...see where I am going with this?) Was it a program that had a reputation for being a happy place to work with reasonable attention paid to resident work/life balance? (OHSU again).

But, Portland is across the country from my family and my support base. About as far as you can get and still be in the continental US. Yes, I have friends there. A lot, actually. Some of them are mothers. But, my kids' dads and grandmas and friends and schools are all here.

I was OK with moving the kids out of the area when my younger son's dad was going to be moving with us. Now that we're separated, I am having serious second thoughts. Not only would there be legal wrangling and custody issues, but I would be starting a residency in a new city as a single mom. It was hard enough arranging child care and new schools for both of them here in Miami. I can't imagine trying to do it in a new, unfamiliar city without two grandmas helping me out. I also don't know if I can justify moving to a new place and then disappearing, for up to 80 hours a week.

Peers in medical school have told me to go for the residency of my dreams, and if mama's happy, the kids will be happy, and it will all fall into place. I am not so sure that is the case. My kids are happy and well adjusted, but there is only so much even happy and well adjusted kids can take.

Throw in the uncertainty of whether I can even get into the local program, the recent uber-competitiveness of ob/gyn and whether I can get into any program at all...sigh. And, if a closer program that I do get into is malignant, and I am stuck there for four years, am I really better off?

That's a tough call. (I matched before I was married or had kids, but it was a tough decision even so!) I've known a few residents that came in to our program with kids and little or no family support who had real trouble, even though the program tried really hard to be as flexible as possible. Excessive absence for *any* reason wears on your colleagues who end up having to cover for you -- no matter how flexible your program is, *someone* has to be on call. However, I think if it were me, I'd probably choose a flexible and friendly program over a more malignant one with family nearby anyway. It will mean more of a hassle for you, finding local childcare and support systems that are available to you during off hours, but that is probably still much easier to do than spending four years in an unpleasant environment and still being able to be an engaged parent. Residency is hard and consuming -- having a family to come home to will hopefully give you more inspiration and emotional support, but also extra responsibilities, so finding a residency that will let you have more of an outside life is really valuable.

I went to OHSU for med school, so I can attest to the fact that Portland is a great town to live in, and OSHU is a great school and very family-friendly in general.

That being said, there are really quite a few very good, family friendly programs across the country. And Portland is a great town, but a bit pricy to live in. Close-in housing is almost unaffordable on a resident salary, and cheaper housing requires more of a commute - meaning more childcare time and less time with your kids.

Residency is, even with the newer work hours rules, long and hard. So is motherhood. You're going to need loving support, and there will be plenty of times when you need to have someone else step in to help with the kids when an emergency comes up or you need to stay for something. You won't own your life well enough to function with just casual friends for help - you need people who really won't mind picking the kids up, feeding them dinner and putting them to bed for you. Often. And when you're on call, you'll need 24-hour coverage.

A nanny or au pair would work, but you have to be lucky in finding a good one who will stay for the duration. And the cost can be pretty high - higher than you may be able to afford on a single salary, especially if you're living in a more expensive location.

The most important thing in residency is finding a place where you can get the experiences you need for your lifelong practice, in as humane a way as possible. Exposure to lots and lots of situations and pathology is probably the best teacher. The good news is that there are lots of programs that can get you that exposure.

Though I loved OHSU and would heartily recommend it, I would also be very hesitant to recommend residency with kids without a very strong support network - either friends/family or paid help. But if money is tight, friends/family may be your only option. If you have that support network already in your current location, I would look again at all of the local options (maybe broaden your search from academic centers to community programs in the area, which are often a bit more family-friendly) and see if some of them might not work (just about) as well.

I don't have kids but I agree w/ OldMDGirl and Anon above--definitely look into (more) local options that may fit the bill for what you are looking for from a training program.

And from experience, I can say it's a bad, bad idea to get your heart set on one program in one place--even if you're single and childless. You can't necessarily control where you end up and the whole process is a lot easier if you go into it with an open mind and a lot of different options that could all work out.

Thanks for all the replies. I am going into ob/gyn. There is only one program within four hours of where I live. One. I guess I could rank the three programs, also, that are four to five hours away, but that is too far for the family support to matter. It will be arguably easier to drive and meet halfway for custody purposes, and it may be easier legally to get approval to move in state than out of state with the kids, even if it's that far.

I would definitely look into hiring an au pair or a live in nanny if I got into any program out of the city (which is problematic for reasons listed above: cost, retention issues) which is all of them but one. My kids will be 13 and 8. There are some nice programs within an hour of my brother and sister-in-law's place in Western New Jersey. I would have to gauge her willingness to take on two more kids to her load of three.

Ob/gyn was very competitive last year, and I know a few people who had to scramble into spots outside of the specialty and are reapplying this year. According to the data from the recent match, I would have the best chances of matching in my specialty if I rank 10 places.

I am reluctantly considering another specialty, but I trained as a midwife for two years, did a research fellowship on labor and delivery interventions, have a publication and more in the works in the field, was president of the ob/gyn interest club, and am in love with obstetrics. I live in an urban area where no family practitioners have obstetric priviledges, and they even have trouble with them if they do a fellowship.

Sigh. I am leaning toward ranking the local program first, but am not sure how to rank the other programs. I am sure I will shuffle and amend my list a lot.

I am a mom and a doc and this only comes from a child of absent (due to work-related travel) parents, but have you considered having your soon to be ex take full custody of the kids at least for intern and PGY2? I know it would kill me to be away from my kids but maybe it would be ok for them for a couple years if you are within 4 hours driving distance. From someone with parents that were gone a lot, it was almost more disruptive to have them in and out all the time instead of one that was a steady influence and consistently around. I don't know... just a thought. Also, au pairs aren't that pricey but they also are not as keen to care for older kids.

I'm *only* a premed and if this week has taught me anything (my son has been home sick all week with a particularly nasty virus), it is that I simply cannot do this without family support close by or the money to spend on a nanny...which, as a premed, I do not have. ;) I plan on trying to stay put for both med school and residency, if I can.

It sounds like a difficult decision, I know it would be a tough call for me to make. With your kids being a bit older, it might make these decisions easier if you get their input. Listen to your instincts as well, we often have more answers than we think we do! Good luck, we're rooting for you!

I used to live 3000 miles away from my parents and in-laws and it really really sucked. When I had an emergency, I didn't have family to rely on. Moreover, any trip to visit family was agonizingly long (travel + kid = teh suck). Moreover, when family did come to visit, they always stayed for freaking ever cuz it was so far and I wanted to kill myself.

Now we live a four hour drive away and it's light years better, even though we're not exactly around the corner.

Gosh, this is a tough one. I wish I had the answer. I think you have some great advice from above and I hope with all your experience and research that maybe your local match won't be as bad as you think.

It is really much easier to be local and have family - that was the driving force by my decision to stay in my hometown, even though I dreamed of training elsewhere so I wouldn't fall too much a victim to academic incest. But I think I did quite nicely, in retrospect, and I got great training.

I also know of people that had kids without family support, but it was more of a struggle and there were two of them.

I moved across the country to be closer to my folks and work in a place that didn't suit me. No regretsYou need a support systemYour career will have ways of working itself out, ( I am from Australia so don't understand the ins and outs of your system but even if its a few years down the track, you will be able to make positive changes to your work) Meanwhile your kids are surrounded by people who care for them, no custody battles hopefully,

I am normally a "follow your dreams" girl all the way, but since I have had my babies i have realised the flexibility of the way you achieve your dreams is important.

You can't truly enjoy work unless things are sorted at home. Good luck!

I moved across the country to be closer to my folks and work in a place that didn't suit me. No regretsYou need a support systemYour career will have ways of working itself out, ( I am from Australia so don't understand the ins and outs of your system but even if its a few years down the track, you will be able to make positive changes to your work) Meanwhile your kids are surrounded by people who care for them, no custody battles hopefully,

I am normally a "follow your dreams" girl all the way, but since I have had my babies i have realised the flexibility of the way you achieve your dreams is important.

You can't truly enjoy work unless things are sorted at home. Good luck!

My advice to students is to always choose support system over specific program. No matter how "family-friendly" a program is, having to mainly rely on nannies/daycares/au pairs as a single parent doing residency will be significantly harder than having family close by, in my opinion. I made the decision of ranking programs I loved and thought would better suit my career goals below the one I ranked first (often called "malignant" by others)...because of where my soon-to-be fiance was. Absolutely glad about that decision and got amazing training.

As a current intern with a husband who is also an intern and a 6 month old baby - I say stay close to your support system! We have my parents and his parents both within a couple hours' drive and my MIL is the primary caregiver for our son. Internship sucks no matter which field you choose and I'm not sure how we'd manage if we didn't have family here. There will be times that we need childcare starting at 530am because that's when we're out the door. And then not home until 8pm. And we have call schedules that mean we might both be gone overnight. It would be really hard to be in a new city trying to have people you trust watch your kids when you're gone so much...

Thanks for all the advice. I talked to one of my attendings who knew someone who was a graduate of our school who left the program after his PGY1 year. (Which was one of the reasons I was afraid the program may be malignant). Believe it or not, it allayed some of my fears.

I knew he left and went into internal medicine, but I was afraid it had more to do with the program than the field not suiting him. Turns out he talked to the attending extensively after he decided to leave the program, and had nothing but good things to say about it. He just didn't love ob/gyn. If there was anything negative about the program, he could have tried to defend his decision to leave by blaming the program, but he didn't.

I feel relieved, and reassured that everyone here seems to agree that ranking the local program first makes sense. Not only would it be easier for me to have a good support system, but I think it will be emotionally healthier for the kids. Plus, it will be easier for me to do a lot of electives at the program without having to travel.

As a gen surg resident with a toddler this one is easy for me: go where you will have the most support. It is the only way you can get through this type of residency with young kids. I have friends, family, au pair, day care, and I call upon all of them on a weekly basis. Still there is a feeling of desperation when you realize that your child is sick and needs to stay home and you are on call. Even progressive and family-friendly residency programs cannot easily accommodate sick days and schedule changes. Having a grandma or aunt who can help in a pinch is truly priceless and takes away a lot of the guilt and anxiety.

(I too am considering Ob/Gyn. I would love to stay at my home program, but I haven't been feeling too much love from them these days so I don't know how much of a shot I have with them).

If I were single, I'd probably apply up and down the map. As it is, I can only apply to a maximum of 7 places. I know it sounds like a good number but the way Ob/Gyn has become more competitive these days has me worried that it is not enough. I have a bad feeling come match day, I will be left high and dry.

I've started looking at another less competitive field as a backup. There are more options in my area in this field and it is considerably less time consuming than Ob, however it is not my preferred field.

My wife gives me mixed signals daily. I know she would rather not move. Any move would make her miserable, and thus make me miserable. This whole situation is causing me to build up serious resentment.

I do not have children, am married, and did residency in internal medicine, not OB/GYN. I would say to stay as close to family support as possible. The differences in program work hours are much smaller than they appear from the outside, especially given strict ACGME oversight of all residencies. No matter what program you choose, you will not have control over your time. It will be much more difficult than medical school, and the responsibilities to patient care will fall upon you in a way that they have not before. There are times when you will be STUCK in the hospital, unable to leave, and you will need someone to take care of your children whom you trust completely, in a pinch. Your family is best for this. To be quite honest, sometimes you will need someone to take care of YOU in a pinch (i.e. - rides home from the hospital after an exhausting call night, someone to bring over takeout when the fridge is bare, etc.). Nothing beats the support of the network that you have already established throughout your medical school years. You will have the rest of your professional life to find your perfect job and colleagues with whom you are in-sync, and you will be negotiating from a much more powerful position at that point.

Stay with your people!!!! We don't live near any family and emergency child care (sick kid, sick nanny, late consults, have to go back to the hospital at midnight, working holidays)comes up all the time. I have had to pack my two year old up at 4am and cart her into the ICU with me because her dad was at work and someone sick needed my attention.

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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